Complaint Investigation Report

Allegation: Resident was hospitalized due to staff neglect.

The outcome of LP’s investigation revealed that on 1/3/21, R1 was hospitalized, and his Emergency Department/Hospital course documentation revealed that there was a high probability of sudden, clinically significant, and or life-threatening deterioration due to hypoxia and septic shock which required the highest level of physician preparedness to intervene urgently. Interviews conducted with facility staff and investigatory leads revealed that R1 was not sent out to the hospital when observed by facility staff not at his normal baseline or a change in condition.

Interviews conducted were consistent in stating that R1 was not at his normal baseline for days and or up to three weeks, at which and during this time R1 sustained unwitnessed falls and required higher level of care. R1’s change in medical condition was communicated with his POA/Sister and at the request of the POA, facility staff did not transport R1 to the hospital for further evaluation. Facility staff did not ensure that any changes in R1’s medical and physical condition were documented and brought to the attention of R1’s Primary Care Physician. On 1/3/21, R1 was found unresponsive by facility staff, requiring hospitalization. Based on the investigation conducted by LP, there was sufficient evidence found to support the allegation of Resident was hospitalized due to staff neglect.

Allegation: Resident developed multiple pressure injuries while in care.

During the course of this investigation, LP obtained and reviewed R1’s hospital records and facility file and conducted interviews with investigatory leads. The outcome of the investigation revealed that R1 often refused and did not cooperate with his adult diaper changes. Interviews conducted of staff and review of R1’s facility file revealed that R1 was frequently observed to have a wet, soiled and/or smelly diaper. R1 was observed by staff not at his normal baseline and reported to have a series of unwitnessed falls and no longer able to ambulate and considered bed bound weeks prior to being hospitalized. During the interview with the Social Worker at PSJMC, it was revealed that upon admission to the hospital, R1 was diagnosed with Hypernatremia, Septic Shock, Acute Renal Failure, UTI, malnutrition, dehydration and respiratory failure. R1 was placed in ICU and was intubated. The attending doctor also reported that R1 had concerning wounds which looked like burns. Hospital documentation revealed that the wound care nurse was consulted and reported that R1 had sustained wounds and bruisings; however, wounds to his bilateral buttocks and right upper thoracic spine areas were observed to be stage 2 pressure injuries, likely from “not being turned”. Based on interviews conducted and records reviewed, there is sufficient evidence to support that R1’s pressure injuries developed while under facility care due to lack of care and supervision, therefore the allegation is Substantiated.